Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Thursday, September 17, 2009

ClinkShrink and I are working on the psychotherapy chapter for our book-- so far, it's still called Off the Couch.

So Clink doesn't see patients for psychotherapy, her role has been to focus my rambling and to connect the thoughts--- I didn't know she had a talent for this, but she's good!

We started talking about how it is that one person can go to one psychiatrist and be told to come in weekly for therapy, while the same person can see another psychiatrist and be told to return in a couple of weeks for a med check without getting a recommendation for therapy. Clink asked: so where does the recommendation for therapy come from?

Does a patient want psychotherapy and look for a therapist who offers this?

Or does a patient go to a psychiatrist with a problem, get evaluated, and have psychotherapy prescribed to treat their problem just like one gets handed a prescription, as part of the package known as the treatment plan?

And what about those patients who come with preconceived ideas about what they need an unwillingness to entertain other options--so the patient who wants therapy but refuses even a trial of medications, or the patient who calls and says before they're even evaluated that they just want to be seen every three months for meds and aren't interested in talking?

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comments:

I saw a NP first and started a Rx, but I didn't feel comfortable enough with her to talk about anything too serious (it was an emergency so I went to the person with the first open appt.). Then when I found my shrink I went primarily for med. mgmt. but on the second visit or so I felt comfortable enough with him to ask if we could schedule therapy visits and he said Sure.Unless you're in the legal system and you're forced, don't the patient and Dr. figure it out between themselves?

What about the psychiatrist (or therapist, for that matter) who has a preconceived notion about what the patient needs-- absolutely meds or absolutely therapy, and an unwillingness to entertain other options?

Or how about the psychiatrist who manages only meds but is unwilling to discuss clinical observations or progress with the patient's therapist? (i.e., not contact the therapist, or not return his/her calls)

I don’t think it’s a binary answer of “either” “or” as to who orders psychotherapy and where it comes in during the process. Just as there are complex issues in treating/experiencing mental health issues, so there are complex issues in prescribing/seeking therapy. In my case, I started therapy with a psychologist to address some grief issues, made the decision to terminate and as the process was drawing to a closet, started to experience the onset of a depressive episode which I didn’t realise at the time. The episode worsened in intensity and I ended up in a psych hospital for five weeks late last year.

There I began seeing a psychiatrist who I still see. About three months after my discharge, I felt the need to dig further into some of the issues that arose from my depressive episode and the subsequent hospitalisation, especially being a psych patient which was never one of my life’s ambitions. I made the decision to go back to my psychologist as I wasn’t get the same depth or traction from my psychiatrist. So in some ways, I ended up developing my own treatment plan which has been extraordinary effective. As much as I hate the word consumer and as much as I value and respect the care from my doctors, we should always remember that consumers have a voice in the process

All of the above are true. The job of the psychiatrist is to educate the patient (and maybe significant others) about diagnosis and available treatment options, tell them which one(s) her/she can provide, refer to other providers for treatments the psychiatrist cannot provide, and let the patient decide.

My concern is if psychiatrists are always the best trained individuals to provide talk therapy. There are many professions that provide this therapy...psychologists, social workers, occupational therapists, etc... Are psychiatrists still trained to be psychotherapists?

The only psychiatrist who would take me after my hospitalization was a meds-only guy. He never looked me in the eye and misquoted the little I said to him which made me want to say even less.

After a while I called back the kind psychiatrist who had told me he specializes in psychotherapy, but his practice was full. When I called back 7 months later, he took me. It was the best decision I ever made. I have been off meds for 3 years now which gave me my life back. I was an emotionless robot on meds and off, I can feel again.

Ladyk73, as someone who completed psychiatry residency training (at one of our nation's "top programs") only 3 years ago, I can say that the answer to your question is absolutely, emphatically, undeniably no.

Some psychiatrists see people for psychotherapy, some don't....so it can be any combo (there wasn't a 'right' answer.

Psychotherapy training for residents varies greatly--depends on the program and the interest of the resident. In some programs, it's only really there if the resident pursues it.

I actually think this is good--psychotherapy is an important part of treatment, but to do it well, the doctor needs to Want to be there-- how do you listen with concern if you're someone who doesn't like listening to people complain? If you don't want to hear their whole long stories? Oh, I just thought of a post!

I first tried therapy about 6-7 years ago and I met with a psychiatrist who only did meds. I felt comfortable talking to him but he wanted me to meet with the psychologist that worked in his office. She was soooo weird! I was completely uncomfortable talking to her and she just kept telling me what I should be doing (BTW, they were things I'd never do in a million years!! If she actually listened to me, she would have known that.) So, I quit going after a few sessions. I decided to give it a try again last summer. I wanted to find a pyschiatrist that does talk therapy as I prefer to just see just one doc. Like April mentioned, I had practical matters to consider. I needed someone on my insurance plan who is close to my office. I lucked out this time and found a great doctor. We've had our rough spots (probably mostly because of me) but I'm glad I gave it another try.

As far as meds and a preconceived notion about them goes, I figured that knows what she's doing. She went to medical school; I didn't. I read up on what was prescribed to me and had questions but just trusted her and they've worked out just fine.

Anonymous---I think you're overgeneralizing. My pdoc went to one of the top medical schools, too, and then residency at a top west coast hospital and WAS apparently trained in talk therapy. And he was quite good at it. I'm sure some are meds only, but not all.

In my experience as a psychotherapist, I often work together with a psychiatrist, and refer clients who may need antidepressant or anti-anxiety medication in order to do the work of therapy. This collaborative approach has been very successful for me. Although I come from a wellness approach, and do not view depression as pathological, for some clients of mine, an antidepressant to get to a "baseline" for the challenging work of self-exploration can be helpful.

I started talking to a minister at my church, (at the risk of sounding paranoid, I'm going to add into this, that my church is a liberal little UCC church in the middle of nowhere, and that I am a good liberal girl.) and when she went on sabbatical, she suggested that I see someone else to talk to. I did, for a few weeks. Then, at some point, I started seeing a guidance counselor at my school, and then, when I was quite depressed, saw my GP who prescribed some meds, suggested therapy, (I went back to the same person I'd seen while my minister was gone) and gave me a referral to a psychiatrist.

I think it is probably different with children. I'm a psychologist, and I find that most parents want to start with psychotherapy, and they are reluctant to consider medication for their child even with my recommendation. I am glad that they are cautious, but it troubles me how the popular press has unnessarily scared them about meds. I wrote a post about this that elaborates on what I've just said.Parents Are Concerned about Psychiatric Medications

I'm also inclined to refer a teenager to a psychiatrist for both meds and therapy with more severe conditions (such as Bipolar Disorder or serious substance abuse), especially, when parent management is not enough to get the teen's cooperation in controlling symptoms.

I think it depends on what the intents of the client, the clinician, and the insurance company are. After all, most people these days seek treatment through their insurance companies. Unfortunately, most insurance companies in the US, see mental health as a problem that can be treated through a medical model. Insurance companies dictate what services are provided, often require a diagnosis, and determine length of treatment. I also believe a good deal falls on the psychiatrist's belief of mental health, the importance (or lack) of psychotherapy, and explanation to client what would be beneficial for successful treatment. While a client can decline psychotherapy (often due to fear of expressing feelings and thoughts), the psychiatrist has the responsibility of explaining the benefits (assuming the dr. believes there are benefits) to incorporating psychotherapy, whether it be through the psychiatrist him/herself or an outside professional.

I saw a therapist due to some family stress, with no thought whatsoever that there was a biochemical explanation for my 20 years of anxiety and depression. We came to the difficult decision together that I should see a psychopharmacologist and take meds. When the AD revealed (nice way of putting it) that I in fact had bipolar 2, I needed my therapist more than ever, and still do, to support me and "hold" my story.

I say Never Again. I saw several psychiatrists both immediately after I lost my oldest child, and a year later when I was briefly hospitalized. The result: permanent tinnitus and hearing loss (Wellbutrin) and permanent inability to cry, and flattening of emotion (Effexor. Yes, it really does happen.) I saw in the psychiatric profession only PD (pharmaquackery disorder), arrogance, ignorance, and irresponsibility. sign me: Former patient.

After a lifetime of wanting help, finally hooked up with someone in my congregation who intro'd me to both my first psychiatrist and first and current psychologist whom I see for weekly therapy.

There's some spiritual aspects that are behind how that happened, how everything came together, involving a moment when this lady's husband first showed up on my doorstep and when I saw him and began our conversation, I knew it was the beginning of the next step in my life; the step where I finally got to get help. That prolly won't make sense to you without more backstory, it's not a huge backstory but more than I'd like to type right now. If you want more, email me. Because for me, I literally knew some kind of help was going to be starting soon when I opened the door that day.

Kinda big for me, when I'd been praying my whole life for wth is wrong with me . . . . and how can i fix it. Of course, once your prayer for help is answered, then there's the, beware what you ask for, cause you gotta be willing to work on fixing it . . . .

Anyway.

I've talked before about my first iatrist, and my second one is no keeper either. He's not much of a businessman, and about never returns phone calls, and i haven't seen him since the last day of July . . . . much as I hate to do it, I'm going to have to do the rounds of iatrists on my plan and beg until one of them will see me, and hope I don't end up with a loser again (this one said he gets on avg. 8 new pt requests a day, which of course a practice can't absorb).

And then there's my psychologist, but I'm in the middle of some bad transference w/him so that's kind of a mess, but I'm so grateful that I got started with him.

Oh, how THAT happened, after I was intro'd by the one lady, was, well, I didn't know I could see him for Therapy; the one lady had taken me to see him once as we were working together on my Social Security Claim, and then he asked if it was ok w/me for her to come in at the end and i said ok, and she came in and we all talked for a few. Cause I was scared and stuff. Anyway, we got what I needed for the Social Security claim, and that was it . . . . this lady was also working with my clergy, because I certainly couldn't pay for that visit; my church paid for it. Now, my church DOES have what's called LDS Social Services, with counselors and social workers and even a few psychologists and psychiatrists, but with all the problems I had (mostly undiagnosed at this point) I was seen as too heavy, too much for LDS Social Services to handle.

Anyway, a couple months after I saw the psychologist the one time, I had talked with my clergy and he had mentioned that I should be continuing to see ALL my doctors . . . . . it was then I realized that going back to see the psychologist was actually an option, maybe. So I did, called him up.

I saw him, we did a first visit kinda thing, and at the end of it he said he believed he could help me and that he'd see me again next week.

I asked, disbelievingly after so many years of hoping and praying for help, "You mean . . . . therapy? I can have therapy? You think you can help me?" I said, as tears rolled down my face . . . .

He said, "Yes." We already both knew that it was arranged to be paid for through my church, at least for a time. As soon as I could, though, I took it off of that, but that did take awhile.

I just . . . . couldn't believe that I could now have help. I had started seeing the psychiatrist about two to three months earlier, around the time I had first seen the psychologist for the Social Security thing. What I hadn't known, was that I had permission or was supposed to access that psychologist for help, at my clergy's urging, and not just the psychiatrist. I hadn't realized I had access to therapy.

Anyway I've rambled on and definitely left chunks of the story out but there it is, pieces of it anyway.